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Sa1593 Comparing the Feasibility and Efficacy of Combined Endoscopic and Transumbilical Single-Port Laparoscopic Surgery With Standard Laparoscopic Resection of Gastric Stromal Tumors Wen LI*, Zikai Wang, Baoqing Jia, Xiaohui Du, Xiaopeng Wang, Tingting Huang, Xuan Su, Lili Wu, Xiuxue Feng Gastroenterology and Hepatology, the Chinese PLA General Hospital, Beijing, China; Department of Oncological Surgery, the Chinese PLA General Hospital, Beijing, China; Department of General Surgery, the Chinese PLA General Hospital, Beijing, China Background: Complete endoscopic or laparoscopic resection of gastric stromal tumors (GST) in the cardia & fundus is only partially feasible. A combined endoscopic-laparoscopic approach has been recently recognized as the favorable modality for these lesions. Aims: To assess the feasibility and efficacy of combined endoscopic and transumbilical single-port laparoscopic surgery (CETSLS) for the GST. Methods Between April, 2010 and July, 2013, 14 patients with GST were assigned to undergo CETSLS (n Z 7) and standard laparoscopic surgery (SLS) (n Z 7) at the Chinese PLA general hospital. The subjects undergiong CETSLS were managed with laparoscopy-assisted endoscopic techniques (i.e. endoscopic snare resection, endoscopic mucosal resection and endoscopic submucosal dissection) or endoscopy-assisted laparoscopic techniques (i.e. laparoscopic gastric wedge resection). Several parameters were analyzed: operation time, conversion rate, operative complications, pain scores, cost and duration of hospital stay, cosmetic satisfaction and follow-up evaluation. Results: There was no difference in the age, gender and indications for CETSLS and SLS groups. All lesions were located in the gastric cardia/ fundus, They were confirmed to be GST on immunohistochemical staining and showed similar mean diameter. CETSLS was successfully carried out in 85.7% (6/7) of our patients with one case requiring conversion to open surgery due to intraoperative bleeding. However, there was no conversion in the SLS group. The mean operative time was similar in both groups (108.0 59.2 vs. 164.3 49.3 minutes: P Z 0.09). The intra-operative blood loss was lower in CETSLS than SLS group (25.0 15.2 ml vs. 74.3 32.6 ml: P Z 0.006). Complete resection rate was 100%. It was achieved without serious complications in both groups. Despite a shorter postoperative hospitalization time in the CETSLS group (5.7 1.4 vs. 8.9 2.8 days, PZ 0.03), the cost of hospitalization was almost similar (40942.8 11158.6 vs. 57246.7 16049.4 RMB, P Z 0.06). There was no re-admission or tumor recurrence during a median follow-up of 26 months (range, 4 43 months). Conclusions: CETSLS is a feasible and effective technique, which offers superior cosmesis during resection of the GST.

25 Background: The national gastric cancer screening program including endoscopy has been introduced in Korea in which the high incidence of gastric cancer have been reported. The good quality indicators of screening endoscopy for gastric cancer are mandatory to improve the detection rate. However, most quality indicators were focused on the standardization of an endoscopy unit rather than the individual assessment of endoscopists for cancer screening ability. We aimed to identify quality-assessment indicators associated with screening gastric cancer. Methods: The database records for 54,889 subjects who underwent esophagogastroduodenoscopy (EGD) for screening purpose at the Yonsei University Severance Hospital Health Promotion Center, Seoul, Korea between February 2006 and July 2013 were analyzed. All the endoscopists (n=66) involved in this study were experienced endoscopists who performed 1,000 or more EGDs. The detection rate of early gastric neoplasm according to endoscopists were assessed. The detection rates of various gastric lesions other than gastric epithelial neoplasms were also analyzed. The scoring formula for predicting the qualified endoscopists was proposed and analyzed. Results: Of the enrolled subjects, mean age was 48 years and the percentage of males was 59.7%. The percentage of gastric dysplasia, early gastric cancer, and advanced gastric cancer was 0.18%, 0.10%, and 0.04%, respectively. Most frequently detected lesions were gastric erosions (22.30%) followed by atrophic gastritis and intestinal metaplasia. In multivariate analysis, the detection rates of gastric subepithelial lesion or gastric diverticulum were independent associate factors with early gastric neoplasm detection. Cochran-Armitage trend test confirmed that higher quality score group was associated with significant higher early gastric neoplasm detection rate. Conclusions: The detection rates of gastric subepithelial lesion or gastric diverticulum are well correlated with early gastric neoplasm detection. the proposed quality score formula can be a good indicator assessing endoscopist's ability to detect early gastric neoplasm.

Background/Aims: Although several experimental and epidemiological studies suggest that statins may have antineoplastic properties, the impact of statin use on patient survival after a curative resection of gastric cancer is unknown. The aim of this study was to investigate whether the use of statins was associated with recurrence or survival after radical gastrectomy in stage II and III gastric cancer. Methods: We conducted matched case-control study of 65 statin user cases and 176 statin non-user cases after radical gastrectomy from January 2006 to December 2009. The controls were matched to cases by age, sex, stage, and operation month. In comparison of baseline characteristics, tumor differentiation, Lauren's classification and Charlson comorbidity index showed statistically differences between two groups or subgroup analysis. Therefore, after adjustment of these different factors we performed Cox regression to identify the association between statin use and gastric cancer outcomes. Results: Recurrence free survival (RFS) between statin user and non-user was similar (adjusted hazard ratio of cancer recurrence or death = 1.518, 95% confidence interval (CI) = 0.761 to 3.03; p = 0.236). Overall survival (OS) was also similar between two groups (adjusted hazard ratio of death = 1.169, 95% CI = 0.57 to 2.397; p = 0.669). We also divided the statin user group into two groups according to the duration of statin use by six months. And then, we compared with three groups which were statin non-user, statin user less than 6 months and statin user more than 6 months. Statin user less than 6 months was associated increased recurrence risk (adjusted hazard ratio of cancer recurrence or death = 1[statin non-user as reference], 3.165 [less 6 months group, 95% CI = 1.337 to 7.491] and 0.368 [more 6 months group, 95% CI = 0.099 to 1.374]; p = 0.008), whereas statin user more than 6 months was showed statistically significant improved OS (adjusted hazard ratio of death = 1[statin non-user as reference], 2.405 [less 6 months group, 95% CI = 1.056 to 5.477] and 0.168 [more 6 months group, 95% CI = 0.032 to 0.881]; p = 0.006). Conclusions: Statin use was not associated with improved RFS and OS in patients after curative resection of stage II, III gastric cancer. However, subgroup analysis demonstrated that long-term statin use more than 6 months was associated with increased survival outcome. Our result firstly suggests antitumor activity of statin treatment with regard to post-operative period of gastric cancer, which has to this day not been fully elucidated.

were the cutting line of submucosal layer exposure rate during dissection (primary end point measure), procedure time, specimen size, submucosal injection frequency, and perforation rate (secondary end point measures). Results: The cutting line of submucosal layer exposure rate during dissection was significantly higher in the sutured material group (0.82 0.14 vs 0.44 0.15, P .000) and external grasping forceps group (0.85 0.11 vs 0.44 0.15, P .001) compared with the conventional ESD group. The mean procedure time was less in the sutured material group (24.2 8.9 minutes vs 35.1 13.2 minutes, P .003) and external grasping forceps group (23.0 8.1 minutes vs 35.1 13.2 minutes, P .001) compared with the conventional ESD group. Three perforations in the conventional ESD group and one perforation in external grasping forceps group developed. There were no significant differences in specimen size, submucosal injection requirement between the three groups. Conclusions: Counter-traction techniques using suture material or external grasping forceps allows endoscopists to achieve direct visualization of the cutting line of submucosal layer. These techniques are useful for more effective and safer ESD.

G A A b st ra ct s in an inpatient cohort from Olmsted County, MN. Information on maximum change in serum creatinine (highest value compared to baseline over the past year) and WBC within 7 days of CDI diagnosis was obtained for three groups: pediatrics ( ,18 yrs old), adults (18-65), and the elderly (.65). Sensitivity (Se) and specificity (Sp) of various levels of WBC and creatinine ratio were estimated for predicting severe-complicated CDI, defined as need for ICU admission, colectomy, or death. Analysis of creatinine ratio in the pediatric population was not done due to a high proportion of missing baseline creatinine values. The cohort included 1446 patients (48.6% female, median age 62.5 yrs [range, 0.1-103.7]); 487 (33.7%) had severe-complicated CDI. A WBC .15 x10^9/L (the cut-off recommended in expert guidelines) had a similar Se and Sp for predicting severe-complicated CDI in pediatrics (Se= 54.5, Sp=78.8), adults (Se=53.7, Sp=73.2), and the elderly (Se=56.3, Sp=63.5). A serum creatinine ratio of 1.5 had a similar ability to predict severe-complicated CDI in adults (Se= 59.2, Sp=59.5) and the elderly (Se=61.9, Sp=54.1). Lowering the thresholds of WBC and creatinine ratio increased the Se but decreased the Sp for predicting severe-complicated CDI in all age groups. For example, lowering the WBC threshold to 12.5 or decreasing the creatinine threshold to 1.4 increases the Se by 10-18% with a similar decrease in Sp (Table 1). No optimal WBC or creatinine rise cut-offs to predict severe-complicated CDI were defined in this investigation. The current cut-off values according to expert guidelines performed similarly across age groups, but had relatively low sensitivities and specificities. For all age groups and for both WBC and creatinine rise, decreasing the cut-off value increased the sensitivity while decreasing the specificity; these variables should be considered as continuous predictors of complicated CDI, with higher values indicating higher risk. Values below the threshold values defined in current guidelines do not reliably exclude a significant risk of complicated CDI. Given the poor outcomes in patients with severecomplicated CDI and the recommendation that treatment be stratified by severity, a more sensitive predictor (lower WBC or creatinine cut-offs) may be more appropriate. Table 1. Sensitivities and specificities of peripheral leukocyte count and serum creatinine rise in predicting severe-complicated Clostridium difficile infection.

Pilot Study to Assess the Safety and Patient Satisfaction of Early Diet After Endoscopic Submucosal Dissection for Gastric Neoplasm Sunyong Kim*, Kyung Seok Cheoi, Hyun Jik Lee, Choong Nam Shim, Hyuk Lee, Sung Kwan Shin, Sang Kil Lee, Yong Chan Lee, Jun Chul Park Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea Background: Endoscopic submucosal dissection(ESD) is a standard treatment for gastric neoplasm without LN metastasis limited to mucosa. However, there is neither standardized guideline nor research with regard to adequate time to start oral intake after ESD. Methods: A total of 130 patients who underwent ESD for 156 gastric neoplasms by single expert endoscopist were consecutively enrolled prospectively from February 2011 to January 2012. Enrolled patients were radonmized to early diet group and fasting group. In the course of study, 9 patients were excluded. Early diet group starts their meal as clear liquid diet on day 0 and as tolerable diet on day 1. Fasting group kept on fasting for two days. All patients were underwent 2nd look upper endoscopy within 2 days and follow-up upper endoscopy after 2 months after ESD. Results: Total number of early diet group and fasting group were 63 and 57 patients, respectively. Mean age was 62 year ( 9.41). All the gastric lesions were resected by en bloc (100%) and most of them by complete resection (94.17%). Pathologic diagnosis revealed malignancy in 57 cases and dysplasia in 60 cases. Mean size of resected specimen was 42.74 mm ( 17.66). There are no significant difference in clinicopathologic conditions and technical detailes between two groups. There was no significant differences of the increment of abdominal pain score and the rates of bleeding (4.76% vs 3.51%, respectively, p .732) and healing rates of post-ESD ulcer between two groups. However, early diet provided significantly higher patient satisfaction and lower hospital costs compared with fasting protocol (both p 0.001). Conclusion: Post-ESD early diet protocol provides higher patient satisfaction and cost-effectiveness and does not influence on the complication rates such as bleeding or abdominal pain. Our study supports that long period of post-ESD fasting might not be recommended unnecessarily.

G A A b st ra ct s intervention program to help reduce IBS symptoms and resource utilization. Methods: We included twoKaiser Permanente centers. Cases were 50 adolescents from our center diagnosed with IBS and subsequently referred and attended our IBS management program. Controls were 25 adolescents from a nearby center whom were diagnosed with IBS, but had no access to the program. Cases and controls were well matched for age, sex, and baseline healthcare utilization. Our interventional IBS programwas a simple multi-disciplinary behavioral therapy that consists of two 90-minute sessions using education, reassurance, dietary intervention, exercise instruction, and guided imagery. Records were reviewed for GI-related visits and imaging, total visits, and all imaging from the year prior to diagnosis and for 4 years after diagnosis. Results: To determine the extent of healthcare utilization in the year following the diagnosis of IBS, a retrospective chart review was performed and was compared to the year prior to diagnosis. In the year after diagnosis the changes in GI-related visits were +2.05 ± 0.46 for controls vs. +0.75 ± 0.25 for cases (P,0.05) and overall visits were +8.95 ± 1.94 for controls vs. +3.61 ± 1.07 for cases (P ,0.05). Changes in overall imaging studies were +1.85 ± 1.23 for controls and -0.23 ± 0.34 for cases (P=0.06), and change in GIrelated imaging was +1.13 ± 0.79 for controls compared to -0.05 ± 0.25 for cases (P ,0.05). Four-year follow up for GI-related visits were 4.83 ± 0.57 for controls vs. 2.06 ± 0.53 for cases (P,0.05), total number of visits showed 39.38 ± 8.64 for controls compared to 22.07 ± 2.76 for cases (P=0.07). GI-related imaging was 4.23 ± 1.21 for controls vs. 1.03 ± 0.33 for cases (P,0.05) and overall imaging was 11.08 ± 4.03 for controls vs. 2.93 ± 0.57 for cases (P,0.05). Conclusion: The year following the diagnosis of IBS, adolescents visit doctors frequently and utilize significant healthcare resources. This costly year is a "crisis" year. A simple multimodal behavioral program offered shortly after diagnosis of IBS significantly reduces the healthcare utilization and imaging studies in the crisis year and continues to be effective four years after the intervention.

more frequent in the initial differentiated cancer group (22/27, 81.5%) than in the initial undifferentiated cancer group (8/17, 47.1%). In the initial benign group, differentiated RGC was significantly (p 0.035) more frequent in the Billroth II group (10/12, 83.3%) than in the Billrot I group (5/12, 41.7%). Conclusions: Clinicopathological characteristics of RGCs significantly differ according to the initial diagnosis for gastrectomy, reconstruction method and initial histological type of cancer. Precise understandings of these differences may enhance efficacious detection of RGC in endoscopic surveillance after distal gastrectomy.

To assess the clinical significance and the prognostic value of preoperative serum carbohydrate antigen 19-9 (CA 19-9) level in gastric cancer.Between January 2005 and December 2006, 1960 patients underwent surgery for histologically confirmed gastric cancer. Of these, 163 patients had elevated serum levels of CA 19-9 preoperatively, and 1628 patients had normal serum levels of CA 19-9 preoperatively. For this study, 325 patients were selected from the group of 1628 patients by age, sex, and cancer stage to serve as controls. Statistically significant differences in survival rates were calculated using the log-rank test. A P value less than 0.05 was considered statistically significant and was determined using SAS software.The baseline characteristics showed some differences between the two groups with regard to histology. Overall survival (OS) in the elevated and non-elevated group was 37.90 and 68.67 mo, respectively (P0.001). N stage (P = 0.001) was a significant predictor of disease-free survival by multivariate analysis. Also, N stage (P0.001), and the presence of peritoneal metastasis (P0.001) remained independent factors in predicting OS by multivariate analysis. Additionally, preoperative serum CA 19-9 levels were significantly associated with OS in univariate (P = 0.009) and multivariate (P = 0.021) analyses.Serum CA 19-9 can be considered an independent prognostic factor in predicting OS in patients anticipating surgery for gastric cancer.

G A A b st ra ct s without PAC. Methods: Thirty-nine (n=39) consecutive patients proven to have PAC by positive FNA were recruited at the time of diagnosis by endoscopic ultrasound. Two controls, matched on age (±5 years), BMI (±3 kg/m2), and gender, were recruited for each case from patients presenting for elective colonoscopy (n=78). Patients with a previous history of diabetes mellitus were excluded. Serum CA 19-9 and FSG were obtained for all cases and controls. Conditional logistic regression analysis was performed to determine significant predictors of PAC. Descriptive statistics were used to determine the sensitivity and specificity in discriminating cases from controls using CA 19-9 alone, FSG alone, and both in combination. For analysis of CA 19-9 and FSG in combination, elevation in either test above a given cut-off threshold was considered positive. Results: Of the 39 cases, 21 were male (54%) and 18 were female (46%), mean age of cases was 65 ± 9.4 years and mean BMI was 25 ± 4.1 kg/m2. As continuous variables, both CA 19-9 and FSG were significant predictors of PAC. The sensitivity and specificity of CA 19-9 and FSG alone and in combination were determined for specific cutpoints and are tabled below along with the area under the receiver operator curve (ROC). Conclusion: For these cutpoints, the largest ROC value was .936, which corresponded to the combination of CA 19-9 > 37 and FSG > 99. The combination of CA 19-9 and FSG performed better than either test alone for discriminating patients with PAC from controls and may be beneficial as an initial test for screening high-risk groups for PAC.

Background: Although, chemotherapy is one of the main treatment modalities for patients with unresectable advanced gastric cancer, it is difficult to find a universally applicable regimen. Recently, adenosine triphosphate based chemotherapy response assay (ATP-CRA) showed positive correlation with treatment response and survival in some human cancers. It is not certain whether this test can be applicable to gastric cancer, yet. Also, most studies used ATP-CRA on single anticancer drug while combination regimen is commonly used in practice.We prospectively conducted ATP-CRA based on doublet chemotherapeutic regimens in unresectable gastric cancer. Methods: Fifty-five patients with gastric cancer (with written informed consents) were consecutively enrolled between April 2007 and June 2009. ATPCRAs were tested to tumor cells obtained through endoscopic biopsy, using paclitaxel/ cisplatin [DDP], docetaxel/DDP, and irinotecan/DDP as well as single regimen including 5FU, cisplatinum, paclitaxel, docetaxel and irinotecan. All patients were randomly treated with one of above DDP-based doublet regimens into either tailored group where the doublet regimens showing the highest inhibition rate in ATP-CRAs using 3 combinations were administered, or empirical group where blindly chosen combinations were given regardless of ATP-CRA results. Results: The overall success rate of ATP-CRA was 96.4% (53/55). Evaluable thirty-two cases were analzyed (male:female=26:6, mean age: 57.9 years). Median follow up duration was 7.8 months (1.9-24.9). 18 cases and 14 cases were randomly assigned in tailored and empirical group, respectively. The disease control rate was 55.6% and 64.3%, respectively. The median progression-free survival (PFS) and overall survivals (OS) were 120 and 274 days, respectively in tailored group and 148 and 312 days in empirical group (p>0.05). Also, median PFS andOS inmatched group (where administered regimens included the drug with the highest inhibition rate in ATP-CRAs using paclitaxel, docetaxel and irinotecan, 10 cases) were 120 and 177days, respectively and 122 and 312days in unmatched group (remainings beside matched group, 22cases) (p>0.05). Conclusion: ATP-CRA was successfully performed with high success rate in gastric cancer with small amounts of tissue taken endoscopically. Prediction of response to combined chemotherapeutic agents by ATPCRA was not superior to that of empirical combined chemotherapy in advanced gastric cancer. A further study with larger number of patient will be required to confirm the clinical significance of combination chemotherapy assessed by ATP-CRA in unresectable gastric cancer.

Cyclin-Dependent Kinase Inhibitor 2A (CDKN2A) was increased with PPARα deletion and in polyps compared to normal mucosa whilst that of the renal carcinoma cell (RCC) gene was reduced in APC Min/+ PPARα -/-. Conclusions. The genotype of APC Min/+ PPARα -/mice is compatible with loss of PPARα -/function and impacts on genes that may alter susceptibility to polyp formation Fold changes in gene expression associated with PPARα deletion

Background: Gastric adenoma is a direct precursor of gastric adenocarcinoma. However, natural history remains unclear and controversy persists around treatment of gastric adenoma, especially low grade dysplasia. Aim: By analysing the histological discrepancies between forcep biopsy and EMR specimen of the gastric adenoma and their clinicopathologic characteristics, we aimed to propose the indication for endoscopic resection of gastric adenoma. Methods: A total of 538 gastric adenomas (387 low grade dysplasia (LGD) and 151 high grade dysplasia (HGD) histologically proven on forcep biopsies) which were removed by EMR in Severance Hospital between Jan. 2004 and Dec. 2007 Non-neoplastic polyps, submucosal tumors, and gastric adenoma without preceding biopsies before EMR were excluded. Histologic gradings were based on Vienna classification. LGD on forcep biopsies were designated as group I, HGD on forcep biopsies as group II. Univariate and multivariate analyses of the clinical and endoscopic characteristics were performed to analyze factors affecting histologic discrepancies; lesion size, number of biopsy fragments, EMR methods, size of EMR specimen, and endoscopic findings such as surface type, presence of unevenness, fold change, erythema and ulcer. Results: Final diagnoses after EMR included 303 (56.3 %) LGD, 89 (16.5 %) HGD, 104 (19.3 %) differentiated adenocarcinoma, 8 (1.5 %) undifferentiated adenocarcinoma, and 34 nonneoplastic conditions. In group I, 87 (22.5 %) cases showed discordant histology after endoscopic resection; 48 (12.4 %) HGD, 31 (8.0 %) differentiated adenocarcinoma, and 4 (1.0%) undifferentiated adenocarcinoma. In group II, 110 (72.8 %) cases showed discordant findings after EMR; 37 (24.5%) LGD, 69 (45.7%) differentiated adenocarcinoma and 19 (12.6%) undifferentiated adenocarcinoma. In the univariate analysis of group I, lesion size, EMR methods, size of EMR specimen, erythema showed significant relationship with the histological discrepancy. (p=0.025, p=0.000, p= 0.001, and p=0.003, respectively). In the multivariate analysis, erythema was found to be statistically significant factor affecting histologic discrepancies. (p=0.034, OR=2.09, 95% CI=1.057-4.132) In the univariate analysis of group II, lesion size showed significant relationship with the histological discrepancy. (p=0.042) Conclusions: HGD on forcep biopsies needs to be endoscopically resected regardless of their endoscopic characteristics based upon our results. LGD on forcep biopsies with larger size, flat/depressed type, or erythema should be considered candidates for EMR.

Fibrosing mediastinitis is a rare disease that is characterized by the proliferation of dense fibrous tissue of the mediastinum. The pathogenesis of fibrosing mediastinitis is unknown in most cases. However, histoplasmosis, tuberculosis, autoimmune disease, radiation therapy, and other idiopathic fibroinflammatory diseases have been implicated in some cases. Most clinical features are related to an obstruction or compression of the mediastinal structure. Fibrosing mediastinitis is often progressive and occurs diffusely throughout the mediastinum. We encountered a case of fibrosing mediastinitis of a very focal lesion without evidence of mediastinal involvement. The condition was confirmed by biopsy and graft bypass surgery was performed because of SVC syndrome.

Lymphangioleiomyomatosis (LAM) is a rare disease that affects females of reproductive age. It is characterized by the abnormal proliferation of smooth muscle cells in the lung and along the axial lymphatics. We report a case of lymphangioleiomyomatosis presenting as a lung mass. The patient visited the emergency room because of dyspnea upon exertion. The chest X-ray showed a lung mass in the right lower lung field and a pneumothorax in the left lung. Chest computed tomography revealed a sized mass in the right lower lobe and multiple thin-walled small cysts scattered in both lungs. Transbronchial biopsy of the lung mass was performed. The biopsy specimen showed atypical smooth muscle cell proliferation and cystic dilatation of the terminal bronchioles, which confirmed the diagnosis of lymphangioleiomyomatosis. To the best of our knowledge, this is the first case of lymphangioleiomyomatosis presenting as a lung mass.